Does Blue Cross Blue Shield cover Mounjaro?

In this article:

• Does Blue Cross Blue Shield cover Mounjaro?
• BCBS Medicare and Medicaid plans
• Does Blue Cross Blue Shield cover Mounjaro for weight loss?
• Does Blue Cross Blue Shield cover tirzepatide?
• How much does Mounjaro cost?
• How much does Mounjaro cost with Blue Cross Blue Shield?
• How to check whether your Blue Cross Blue Shield plan covers Mounjaro
• How to save on Mounjaro

In this article

• Does Blue Cross Blue Shield cover Mounjaro?
• BCBS Medicare and Medicaid plans
• Does Blue Cross Blue Shield cover Mounjaro for weight loss?
• Does Blue Cross Blue Shield cover tirzepatide?
• How much does Mounjaro cost?
• How much does Mounjaro cost with Blue Cross Blue Shield?
• How to check whether your Blue Cross Blue Shield plan covers Mounjaro
• How to save on Mounjaro

Mounjaro (tirzepatide) is a brand-name prescription medication that’s approved by the Food and Drug Administration (FDA) to lower blood sugar levels in people with Type 2 diabetes. Manufactured by Lilly, Mounjaro is a once-weekly injection available in six different doses. It’s considered a glucose-dependent insulinotropic polypeptide (GIP) agonist/glucagon-like peptide-1 (GLP-1) receptor agonist. Some health insurance formularies cover Mounjaro, while others list it as a nonpreferred drug. 

Does Blue Cross Blue Shield cover Mounjaro?

Blue Cross Blue Shield (BCBS) coverage of Mounjaro varies by plan and the BCBS affiliate (like Anthem) selling the plan. For example, Anthem Blue Cross Blue Shield (Upstate New York) covers Mounjaro in most plans. Excellus Blue Cross Blue Shield does as well. Both list Mounjaro as a tier 2 drug with quantity limits and prior authorization required.

BCBS Medicare and Medicaid plans

Medicare and Medicaid coverage for Mounjaro may be different than coverage offered by private or employer-sponsored plans. For example, although Excellus Blue Cross Blue Shield covers Mounjaro in some individual and family plans, it does not cover Mounjaro in its Medicare plans. In contrast, Blue Cross Blue Shield of Michigan covers Mounjaro in all Medicare plans.

Medicaid coverage varies by state. For example, Blue Cross Blue Shield of Illinois and Blue Cross Complete of Michigan do list Mounjaro as a non-preferred drug but require prior authorization.

Even if your BCBS health plan covers Mounjaro, you may need to get prior authorization from the insurance company to confirm they’ll pay for it. “Insurance companies seem less and less likely to cover medications like Mounjaro due to their cost,” says Megan Horsham, a board-certified physician who specializes in weight loss at The Sanctuary Wellness Institute. “If you do not fit BMI criteria or do not have Type 2 diabetes, your insurance might not cover them.”

Does Blue Cross Blue Shield cover Mounjaro for weight loss?

Blue Cross Blue Shield doesn’t typically cover Mounjaro for weight loss because it’s considered an off-label use of the drug. However, tirzepatide, the active ingredient in Mounjaro, is an FDA-approved weight loss medication under the brand name Zepbound. 

Because insurance companies tend to only cover prescriptions for their FDA-approved use, Blue Cross Blue Shield is more likely to cover Zepbound than Mounjaro for weight loss or sleep apnea, a recently FDA-approved use for Zepbound. That being said, coverage for weight loss drugs is sometimes limited unless the patient has a comorbid condition, like sleep apnea, high blood pressure, or high cholesterol.

RELATED: Zepbound vs. Mounjaro

Does Blue Cross Blue Shield cover tirzepatide?

Tirzepatide, the active ingredient in Mounjaro, isn’t available as a generic medication, so it isn’t covered by Blue Cross Blue Shield. 

Some specialty pharmacies will create their own version of Mounjaro, known as compounded tirzepatide. Compounded drugs aren’t usually covered by insurance because they aren’t FDA approved, and the FDA has shared its concerns about compounded GLP-1s like Mounjaro, such as low-quality ingredients, contaminants, or incorrect dosing. Furthermore, now that the shortage is over, the FDA may take action against compounding pharmacies that compound, distribute, or dispense compounded GLP-1s.

How much does Mounjaro cost?

Without insurance, Mounjaro costs an average of $1,528 per 4, 0.5 mL of 5 mg/0.5 mL pens. With a Mounjaro coupon from SingleCare, you could pay as low as $875 at CVS pharmacy instead, depending on your pharmacy and location.

How much does Mounjaro cost with Blue Cross Blue Shield?

The cost of Mounjaro with Blue Cross Blue Shield health insurance varies by plan. Plans typically structure their prescription costs in one of three ways:

• Fixed copays—including $0 copays—for all prescription medications, with lower copays for generic drugs and higher copays for name-brand prescription drugs like Mounjaro 
• Coinsurance, which means you pay a percentage of the total cost of the prescription, with higher percentages reserved for name-brand prescriptions  
• Full out-of-pocket cost for all prescriptions until the plan’s deductible is met

How to check whether your Blue Cross Blue Shield plan covers Mounjaro 

To find out if your Blue Cross Blue Shield plan covers Mounjaro, call the customer service number on the back of your insurance card or ask your pharmacist for assistance. 

You can also log in to your health insurance portal to access policy documents. The two you want to look for are the drug list (also called a formulary, pharmacy benefits document, or PDL) and the summary of benefits.

Look for Mounjaro on the list of drugs. If it’s labeled as a “nonpreferred” drug, your plan is more likely to cover an alternate medication for Type 2 diabetes, but it may cover Mounjaro if your healthcare provider advocates for insurance coverage on your behalf. If Mounjaro is listed as a preferred drug, it’s more likely to be covered with fewer restrictions.

Some drug coverage lists also assign a tier level to each prescription. Lower-tier drugs tend to have cheaper copays than higher-tier drugs. Check the document glossary to understand the meaning of each tier. 

Once you know the tier level of Mounjaro, check the summary of benefits document to see how much you pay for drugs in that tier. 

How to save on Mounjaro

If your Blue Cross Blue Shield health insurance plan doesn’t cover Mounjaro, you can save money with a free SingleCare prescription discount card. Signing up is easy, and it provides access to instant coupons you can use at most pharmacies. Just find your preferred pharmacy on the Mounjaro coupon page at SingleCare.com, and select the corresponding “get free coupon” button. Save this coupon by printing it or sending yourself a digital copy via text or email. When you’re ready to pick up your Mounjaro prescription, show the pharmacist the coupon. You can also use the SingleCare app to find coupons. 

There are other ways to save money on Mounjaro as well. You can also talk to your healthcare provider about Mounjaro alternatives that may be more affordable, depending on your insurance, such as Ozempic (semaglutide) or Victoza (liraglutide).